Sclerosing cholangitis

Diagnosing Biliary Malignancy

The most common malignant causes of biliary strictures are pancreatic cancer and cholangiocarcinoma. Differentiating between malignant and benign causes of biliary strictures has remained a clinical challenge. Endoscopic retrograde cholangiopancreatography (ERCP) remains the mainstay and first-line method of tissue diagnosis but has a poor diagnostic yield. This article reviews the causes of biliary strictures, the initial clinical evaluation of biliary obstruction, the diagnostic yield of ERCP-based sampling methods, the role of newer tools in the armamentarium for evaluating strictures, and ways to address the ongoing challenge of stricture evaluation in patients with primary sclerosing cholangitis.

Development of hypertriglyceridemia in patients with enterocutaneous fistulas

BACKGROUND & AIMS

Hypertriglyceridemia is commonly observed in patients with enterocutaneous fistulas, compromising their health status. In this study potential causes for hypertriglyceridemia in patients with an enterocutaneous fistula are explored and treatment options discussed accordingly.

METHODS

A database was created consisting of all consecutively treated patients with an enterocutaneous fistula from 1991 until 2007. Two successive measures of serum triglyceride concentrations of more than 3.0 mmol/L (266 mg/dL) were regarded as hypertriglyceridemia. The relation between fistula specific characteristics and hypertriglyceridemia was analyzed using a multivariable Cox proportional hazard model with time-dependent covariates.

RESULTS

A total 102 patients were eligible for this study of whom 25 had hypertriglyceridemia. Multivariable analysis showed that sepsis (HR 4.503, CI 1.778-11.401, P=0.002), high output small bowel fistula (HR 3.534, CI 1.260-9.916, P=0.016), parenteral nutrition (HR 5.689, CI 1.234-26.216, P=0.026) and inflammatory diseases (inflammatory bowel disease vs. malignancy HR 6.211, CI 1.081-35.696, P=0.041) were independent predictors of hypertriglyceridemia.

CONCLUSIONS

High triglyceride concentrations in patients with an enterocutaneous fistula were mainly associated with sepsis, a high output small bowel fistula, nutrition by the parenteral route and primary diseases with inflammatory aetiology. This should direct a treatment strategy that focuses on these aspects.

New insights into autoimmune liver diseases

Autoinflammatory liver disease represents an important aspect of global hepatological practice. The three principal disease divisions recognized are autoimmune hepatitis, primary sclerosing cholangitis and primary biliary cirrhosis. Largely, but not exclusively, these diseases are considered to be autoimmune in origin. Increased recognition of outlier and overlap syndromes, changes in presentation and natural history, as well as the increased awareness of IgG4-associated sclerosing cholangitis, all highlight the limitations of the classic terminology. New insights continue to improve the care given to patients, and have arisen from carefully conducted clinical studies, therapeutic trials, as well as genetic and laboratory investigations. The challenges remain to treat patients before liver injury becomes permanent and to prevent the development of organ failure.

Multidisciplinary approach to benign biliary strictures

The various approaches used for the management of patients with benign biliary strictures are justified by the diverse nature, clinical presentation, and severity of these strictures. Benign biliary strictures are most commonly postoperative, a consequence of injury during laparoscopic cholecystectomy or fibrosis after biliary duct-to-duct or bilioenteric anastomoses (ie, liver transplantation). Less frequently, benign strictures are due to chronic pancreatitis or other nonmalignant diseases, including external compression, parasites, stone perforation, and infections. Because of their peculiar pathogenesis, localization, and short extension into the bile duct, the majority of these strictures can be approached by operative treatments such as surgical bypass and endoscopic--or radiological--dilation. In contrast, primary sclerosing cholangitis (PSC) is a systemic disease with immune-mediated inflammation and subsequent fibrosis of the bile ducts with the development of multiple strictures due to an "intrinsic" liver disease; thus, medical therapy and pharmacologic research are mainly focused on the treatment of PSC rather than other benign biliary strictures. However, none of the previously mentioned benign strictures has a univocal and sole treatment. Any attempt to identify a standard treatment for all the strictures is questionable, inconclusive, and most likely useless due to the diversity of patients and diseases. Gastroenterologists, radiologists, and surgeons work in tight collaboration, not in competition, to individualize the patients' treatment. The morphology and extension of the stricture, its location, the theoretical pathogenesis (eg, intrinsic strictures, strictures due to inflammation and fibrosis after bile leak, ischemic lesions), the patients' specific characteristics (comorbidity and history of prior surgery, including enterobiliary anastomoses and gastric resection), and preferences should indicate the treatment that may offer the patient major benefits with a lower complication rate. Unfortunately, in most of the cases, choosing between different treatments is more likely based on local availability than their actual effectiveness and indication.

Primary sclerosing cholangitis: detection of cancer in strictures

Primary sclerosing cholangitis (PSC) is a significant risk factor for developing cholangiocarcinoma. Tests currently used to screen patients with PSC include serum tumor markers, invasive biliary imaging and sampling techniques, and noninvasive biliary imaging. The most commonly used serum markers are carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA). Invasive biliary imaging includes endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). In addition to standard cytology, the bile can be tested for CA 19-9 levels, as well as other novel tumor markers. In addition, the brushed cells can be analyzed for chromosomal abnormalities using digital image analysis (DIA) or fluorescence in situ hybridization (FISH). Nonivasive imaging techniques include computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and positron emission tomography (PET).

[Precancerous lesions of the gallbladder]

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

The significance of bowel permeability

PURPOSE OF REVIEW

In clinical research, increased permeability has been scrutinized as a potential indicator of the severity of gastrointestinal disease and as a potential cause of the perpetuation of severe inflammatory activity in infectious states. This review discusses old and recent epidemiological and clinical evidence to establish whether increased permeability in sepsis is a sequel or a cause of multiple organ failure. In addition, old and new evidence linking inflammation and permeability in abnormal gastrointestinal anatomy and function to liver abnormalities in susceptible patients will be reviewed.

RECENT FINDINGS

Intestinal permeability has been found to be increased in several gastrointestinal diseases but not to be a very good marker of the severity of disease. Evidence is put forward supporting the claim that increased intestinal permeability is part of generalized leakiness of tight junctions in multiple organ failure and to play a less strong role as a primary event in its pathogenesis. Endemic malnutrition has been shown to be caused by interplay between malnutrition and intestinal inflammation. Recently experimental evidence has been put forward suggesting that enteral fat has anti-inflammatory effects on the intestine via the autonomic nervous system. Old clinical and new epidemiological evidence links intestinal inflammation, disruption of the enterohepatic cycle of bile acids, and liver disease.

SUMMARY

The implications of the described findings are that inflammatory activity, locally induced by abnormal intestinal anatomy and disruption of the bile acid pool, or systemically by severe and uncontrolled inflammation/infection, should be the focus of treatment or research. In addition, the connection between intestinal inflammation and liver disease should be investigated.

Primary sclerosing cholangitis

Primary sclerosing cholangitis is a chronic cholestatic liver disease of unknown origin characterized by progressive inflammation, destruction, and fibrosis of the intrahepatic and extrahepatic bile ducts. The disease leads to obliteration of intrahepatic bile ducts and to biliary cirrhosis, end-stage liver disease, and portal hypertension. Primary sclerosing cholangitis commonly occurs in the presence of inflammatory bowel disease. Its exact etiology remains unknown. As a result, there is no existing effective medical management to delay or modify the progression of the disease. Ursodeoxycholic acid, the most well-studied drug for primary sclerosing cholangitis, has demonstrated promising results when used in combination with an immunosuppressant or antibiotic. To date, liver transplantation remains the only confirmed long-term treatment of primary sclerosing cholangitis, which now accounts for 6% of adult and 1% of pediatric liver transplantations in the United States. Primary sclerosing cholangitis represents an important liver disease with major morbidity and mortality.

Risk factors for intrahepatic cholangiocarcinoma in a low-risk population: a nationwide case-control study

Recently, the incidence of intrahepatic cholangiocarcinoma (ICC) has been increasing in a number of developed (Western) countries. However, risk factors in these low-risk populations are poorly understood. In this nationwide population based case-control study in Denmark, we examined the relationship between selected medical conditions and subsequent ICC risk to provide additional clues to etiopathogenesis. All histologically confirmed ICC cases diagnosed in Denmark between 1978 and 1991 were identified from the Danish cancer registry. Population controls were selected from the central population registry and were matched 4:1 to cases on sex and year of birth. Cases and controls were linked to the Danish hospital discharge registry to obtain information on prior hospital diagnoses. Odds ratios (OR) and 95% confidence intervals (95% CI) were derived using conditional logistic regression. A total of 764 ICC cases and 3,056 population controls were included in the study. Chronic liver diseases were significantly related to ICC: alcoholic liver disease (OR = 19.22, 95% CI = 5.55-66.54), unspecified cirrhosis (OR = 75.9, 95% CI 10.2-565.7). Bile duct diseases were also associated with risk: cholangitis (OR = 6.3, 95% CI = 2.3-17.5), choledocholithiasis (OR = 23.97, 95% CI = 2.9-198.9), cholecystolithiasis (OR = 4.0, 95% CI = 2.0-7.99), though gallbladder removal did not change risk (OR = 1.6, 95% CI = 0.65-3.7). Among other conditions, chronic inflammatory bowel disease (OR = 4.7, 95% CI = 1.65-13.9) was significantly associated with ICC. Diabetes was associated with risk in the year prior to diagnosis of ICC (OR = 3.02, 95% CI = 1.05-8.69). Obesity was unrelated to risk. These results confirm that prior bile duct diseases increase risk of ICC and suggest that alcoholic liver disease and diabetes may also increase risk.